The clinical implications of personality-generated mental illness.

The three scholarly commentaries differ in the extent to which they support the hypothesis put forward, but all agree that personality has an important role in generating mental illness. Livesley (2014) feels that it is going too far to say that personality disorder is responsible for recurrent mental illness, but in saying that personality status influences the course of mental illness, he is, in effect, supporting the hypothesis in a diluted form. Skodol (2014) also rightly points out that personality disorder can, with a certain degree of nosological gymnastics, be diagnosed before the age of 18years. Widiger (2014), as might be expected from a well-grounded personality-informed authority, regards the hypothesis as already tested and proven. It is a sad fact of life that much of what appears to be true around us is so often ignored, and when it comes to practice with the typical patient in the psychiatric clinic, personality disorder, and indeed personality status in any form, takes a back seat in the car that drives clinical decision-making. Everyone who reads this journal would agree that personality status should be an essential part of psychiatric consultation and rightly should include personality strengths and weaknesses (Skodol, 2014), but the readers of Personality and Mental Health are not typical, but in being proud not to be, they should also proselytize the importance of this subject across the range of psychiatric practice. What we are trying to do in presenting this hypothesis is not just to take it in isolation but to take several logical steps forward in considering the clinical implications of the hypothesis. If it was accepted in the form put forward, recurrence of most disorders could be addressed at the first consultation and not, as so often happens, after the patient has failed to respond to what appears to be a reasonable evidence-based treatment. If it is accepted that recurrence is strongly related to personality dysfunction (whether or not we call it disorder), then, de rigueur, it is necessary to clinicians to assess personality and clinical status as a matter of course. If recurrence is not expected, it is also logical to consider whether an episode of common mental illness occurring in the absence of any personality pathology might be treated in a completely different way from others. Bearing in mind that the most common mental disorders fluctuate greatly in their expression over time, and that a great number of them can be perceived as a very common adjustment to stressful circumstances (Casey, 2009), it is certainly reasonable to posit the argument that active treatment of such disorders should be minimal as they are likely to resolve through a combination of very simple